The primary objective of the proposed study is to determine if a clinical algorithm for managing urinary tract infections (UTIs) in older adults in residential long-term care facilities (LTCFs) can reduce the overall use of antibiotics in LTCFs. Three secondary aims are 1) to demonstrate the feasibility of implementing evidence-based diagnostic and therapeutic clinical algorithms in LTCFs, 2) to assess the safety of reducing the number of diagnostic tests and antibiotic use for UTIs in the target population, 3) to evaluate the process of adopting the proposed algorithms in LTCFs. Reducing the use of antibiotics in LTCFs will reduce 1) the potential for the development of antibiotic resistance, 2) the potential for adverse drug effects and harmful drug interactions, 3) significant costs associated with inappropriate use of antibiotics. To achieve the research goals, a randomized controlled trial with participating LTCFs randomized to either intervention (clinical algorithm) or control group will be conducted. An evidence-based diagnostic and a treatment algorithm were developed, augmented with feedback from primary care physicians and nurses working in residential LTCFs. The study will use a combined quantitative and qualitative approach to evaluate the process and outcomes of implementing the clinical algorithm. A randomized matched pair design will be used where, within each of the 12 pairs of LTCFs, one will be randomized to the intervention (clinical algorithm). The other half will provide usual management of presumptive urinary tract infections. Quantitative outcomes will include the following: 1) the proportion of antibiotic courses prescribed for urinary indications, 2) the total number of courses of antibiotics used, 3) rates of urine cultures ordered, 4) hospitalization rates for urinary tract infections, and 5) mortality rates. During the first two months of the study, the algorithm will be pilot tested in the intervention homes. Adoption of the prospective case study evaluation of a health service intervention (diagnostic and treatment algorithms concerning antibiotic use for UTIs in residents of LTCFs) will examine the ease of implementation and healthcare provider satisfaction with diagnostic and treatment algorithms. Using criterion sampling, two groups of respondents will be interviewed, key clinical administrators in the participating LTCFs (medical directors, directors of nursing, infection control officers) and nursing staff who will implement the algorithms.
